Treatment strategies for psychological sequelae If an athlete will not or cannot follow the treatment plan, a psychological factor is generally present. Athlete resistance to treatment usually increases with the severity of the eating problem.138 Treatment should be provided by a mental health professional knowledgeable about the management of EDs in athletes. The frequency, types, intensity and duration of psychological treatment depend on the severity, chronicity and the medical and psychological complications of the eating problem, as well as the comorbid psychological disorders that often accompany such problems. Ideally, eating problems can be treated on an outpatient basis. Medical complications, risk of self-harm and lack of progress in outpatient treatment indicate a need for more intensive treatment regimens including inpatient, residential, partial hospitalisation and intensive outpatient programmes. Treatment is usually required for several months. Treatment modalities might include cognitive behavioural therapy, dialectical behaviour therapy or familybased therapy. Comorbid conditions, such as depression, anxiety and other psychological problems also need to be addressed. Pharmacotherapy may also be recommended; antidepressants are the class of medications most often prescribed.139 Clinical models for sport participation and return-to-play Risk assessment for sport participation There are limited evidence-based guidelines to assist the athlete healthcare team in the assessment for sport participation clearance with RED-S. Based on the guidelines from the Norwegian Olympic Training Center140 and the collective expertise of the IOC Consensus group, a new model of criteria to assess risk for sport participation has been developed (table 1). This model can be incorporated into the PHE. The criteria for Table 1. Relative Energy Deficiency in Sport risk assessment model for sport participation (modified from Skårderud et al)140 High risk: no start red light Moderate risk: caution yellow light } Anorexia nervosa and other serious eating disorders } Other serious medical (psychological and physiological) conditions related to low energy availability } Extreme weight loss techniques leading to dehydration induced haemodynamic instability and other life-threatening conditions } Prolonged abnormally low % body fat measured by DXA or anthropometry using The International Society for the Advancement of Kinanthropometry ISAK141 or non-ISAK approaches142 } Substantial weight loss (5–10% body mass in 1 month) } Attenuation of expected growth and development in adolescent athlete } Abnormal menstrual cycle: FHA amenorrhoea >6 months } Menarche >16 years } Abnormal hormonal profile in men } Reduced BMD (either from last measurement or Z-score < −1 SD) } History of 1 or more stress fractures associated with hormonal/menstrual dysfunction and/or low EA } Athletes with physical/psychological complications related to low EA/disordered eating - ECG abnormalities- Laboratory abnormalities } Prolonged relative energy deficiency } Disordered eating behaviour negatively affecting other team members } Lack of progress in treatment and/or non-compliance BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; EA, energy availability; FHA, functional hypothalamic amenorrhoea; ISAK, International Society for the Advancement of Kinanthropometry } Healthy BMD as expected for sport, age and ethnicity } Healthy musculoskeletal system } Normal hormonal and metabolic function Low risk: green light } Healthy eating habits with appropriate energy availability nummer 4 | september 2014 | Sport & Geneeskunde 21 Pagina 20
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